Practice Essentials
Biliary trauma is rare and includes injury to the bile ducts or gallbladder. Clinicians should have a high index of suspicion in patients who sustain significant right upper quadrant blunt or penetrating injury.
Diagnosis is often delayed, which may increase associated morbidity and mortality.
Endoscopic retrograde cholangiopancreatography (ERCP) has become a minimally invasive strategy to manage partial duct transections and should be considered in hemodynamically stable patients.
Signs and symptoms
Most of the morbidity associated with biliary tract injuries is related to bile leaking into the peritoneal cavity; however, with minimal bile leakage, peritonitis may not occur initially and abdominal signs may be absent. Thus, initial physical findings are often nonspecific.
Late physical findings may include the following:
Right upper quadrant pain
Peritonitis
Jaundice
See Presentation for more detail.
Diagnosis
Laboratory studies
No specific laboratory values exist to diagnose traumatic bile duct injuries. Concurrent liver injuries will likely result in elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels, which should raise suspicion for a biliary injury.
Imaging studies
The following imaging studies have been used in the evaluation of biliary trauma:
Focused assessment with sonography for trauma (FAST): Used to detect fluid in the peritoneal cavity.
Abdominal computed tomography (CT): Can be helpful in determining the etiology of fluid in the right upper quadrant; can also be used to assess for concomitant liver injury in patients with
blunt abdominal trauma.
99mTc-Mebrofenin hybrid single photon emission tomography-computed tomography (SPECT-CT): Used to detect and localize posttraumatic bile leaks.
Magnetic resonance cholangiopancreatography (MRCP): Useful for detecting pancreaticobiliary injuries after blunt trauma.
HIDA (Tc
99m-hepatobiliary iminodiacetic acid) scintigraphy: May demonstrate leakage from the biliary tree.
Endoscopic retrograde cholangiopancreatography (ERCP): Extremely useful for the diagnosis of biliary trauma in stable patients and allows for therapeutic intervention in selected patients.
See Workup for more detail.
Management
The choice of treatment depends on the following factors:
Patient stability
Associated injuries
Imaging findings
If the clinician has a high index of suspicion for concurrent injuries other than a solid organ injury, a diagnostic laparoscopy or exploratory laparotomy may be indicated. In the rare event that an isolated extrahepatic bile duct or gallbladder injury is identified on imaging, endoscopic techniques may be favored.
See Treatment for more detail.